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Introduction to Gait

The ability to walk independently is a prerequisite for most daily activities. The capacity to walk in a community setting requires the ability to walk at speeds that enable an individual to cross the street in the time allotted by pedestrian lights, to step on and off a moving walkway, in and out of automatic doors, walk around furniture, under and over objects and negotiate kerbs. A walking velocity of 1.1-1.5 m/s is considered to be fast enough to function as a pedestrian in different environmental and social contexts. It has been reported that only 7% of patients discharged from rehabilitation met the criteria for community walking, which included the ability to walk 500 m continuously at a speed that would enable them to cross a road safely [1].

Flexibility, i.e. the ability to adapt the movement to changingenvironmental demands and goals.

Gait in Stroke

Poststroke hemiplegic gait is a mixture of deviations and compensatory motion dictated by residual functions, and thus each patient must be examined and his/her unique gait pattern identified and documented.[3] Walking dysfunction is common in neurologically impaired individuals, arising not only from the impairments associated with the lesion but also from secondary cardiovascular and musculoskeletal consequences of disuse and physical inactivity. Muscle weakness and paralysis, poor motor control and soft tissue contracture are major contributors to walking dysfunction after stroke.

balance of the body mass as it progresses over one or both lower limbs

controlling knee and toe paths for toe clearance and foot placement

optimizing rhythm and coordination.

Conventional Gait Training

Conventional gait training has focused on part-practice of components of gait in preparation for walking. It includes

Symetrical Weight bearing training

Weight shifting

Stepping training (swinging / clearance )

Heel strike

Single leg standing

Push off / Calf rise.

Followed by

Circuit training (reaching in sitting and standing, sit-to-stand, step-ups, heel lifts, isokinetic strengthening, walking over obstacles, up and down slopes).

Traditional approaches to stroke recovery have a focus on neurofacilitation or neurodevelopmental techniques (NDT) to inhibit excessive tone, stimulate muscle activity if hypotonia is present and to facilitate normal movement patterns through hands-on techniques.[6] Practice based on the framework advocated by Berta Bobath remains the predominant physical therapy approach to stroke patients in the UK and is also common in many other parts of the world, including Canada, United States, Europe, Australia, Hong Kong and Taiwan. The Bobath framework has evolved from its original foundations, however, therapists surveyed on the core Bobath elements still emphasize normal tone and the necessity of normal movement patterns to perform functional tasks[7]

Treadmill Training

Body weight supported treadmill training was one of the first translations of the task-specific repetitive treatment concept in gait rehabilitation after stroke.[8] Through a systematic review of 6 RCTs of Body Weight Supported Treadmill Training (BWSTT) and 2 RCTs without BWSTT, Teasell et al. [9]concluded that there was conflicting evidence that treadmill training with or without BWSTT resulted in improvements in gait performance over standard treatments. Although the evidence supporting treadmill training appears to be conflicting, two recent clinical practice guidelines recommended that BWSTT be included as an intervention for stroke.[6]

Robotic Assisted Training

Robotic devices provide safe,intensive and task oriented rehabilitation to people with mild to severe neurologic injury. It does

precisely controllable assistance or resistance during movements

good repeatability

objective and quantifiable measures of subject performance,

increased training motivation through the use of interactive (bio)feedback.

In addition, this approach reduces the amount of physical assistance required to walk reducing health care costs [88,91] and provides kinematic and kinetic data in order to control and quantify the intensity of practice, measure changes and assess motor impairments with better sensitivity and reliability than standard clinical scales.[10]

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